The Obese Hypertensive

Behavioral Medicine Review: Weight Control in a Land of Milk and Honey

Obesity and its cardiometabolic comorbidities are on a skyrocketing trajectory with ominous public health implications. Focusing on primary care as a microcosm of the broader obesity crisis, this review discusses considerations for the prevention and management of obesity and its associated risks.

The Role of Beta-Blockers in the Treatment of Hypertension

IMPORTANCE

Two major guide-line committees (JNC-8 and NICE UK) have dropped beta-blockers as first-line therapy in the treatment of hypertension. Also, recent meta-analyses (that do not take age into account) have concluded that beta-blockers are inappropriate first-line agents in the treatment of hypertension. This review seeks to shed some light on the "rights and wrongs" of such actions and conclusions.

OBJECTIVES

Because the pathophysiology of primary/essential hypertension differs in elderly and younger subjects, the latter being closely linked to obesity and increased sympathetic nerve activity, the author sought to clarify the efficacy of beta-blockers in the younger/middle-aged group in reducing the risk of death, and cardiovascular end-points.

EVIDENCE ACQUISITION

Four searches were undertaken, utilising PubMed up to 31st Dec 2015. One search was under the terms "hypertension AND obesity AND sympathetic nerve activity". A second was "hypertension AND plasma noradrenaline/norepinephrine AND survival". A third was "beta-blockers or adrenergic beta-antagonists AND hypertension AND age AND stroke or myocardial infarction or death". A fourth was "meta-analysis of beta-blockers AND hypertension AND age AND death, stroke, myocardial infarction" RESULTS: Diastolic (with or without systolic) hypertension, in contrast to isolated systolic hypertension, occurs primarily in younger subjects, and is linked to overweight/obesity and increased sympathetic nerve activity. In younger/middle-aged hypertensive subjects, high plasma norepinephrine levels are linked (independent of blood pressure) to an increased risk of future cardiovascular events and death. High resting heart rates (a surrogate for high sympathetic nerve activity) likewise predict premature all-cause death, coronary heart disease and cardiovascular events in younger hypertensive subjects. In this younger/middle-aged hypertensive group, antihypertensive agents that increase sympathetic nerve activity (diuretics, dihydropyridine calcium blockers, and angiotensin receptor blockers (ARBs)) do not decrease (and may increase) the risk of myocardial infarction, and are therefore inappropriate first-line agents in this age-group. By contrast, in younger/middle-aged hypertensive subjects (less than 60 years old), meta-analysis has shown that beta-blockers are significantly superior to randomised placebo, and at least as effective as randomised comparator agents, in reducing death/stroke/myocardial infarction. In this younger/middle-aged hypertensive group beta-blockers have been shown (vs randomised placebo or diuretics) to reduce the risk of myocardial infarction by 35-50 %, and stroke by 50-55 % (vs placebo), in non-smoker men. Atenolol was at least as effective as ACE-inhibition (captopril) in reducing all 7 cardiovascular endpoints (including stroke which was reduced by 50 %), vs less tight control of blood pressure, in obese hypertensive subjects with type-2 diabetes (UKPDS study); and after 20 years follow-up, atenolol was significantly (23 %) superior to the ACE-inhibitor in reducing the risk of all-cause death (beta-blockers have anti-cancer properties, which maybe relevant).

CONCLUSIONS AND RELEVANCE

Primary/essential hypertension in younger/middle-age is underpinned by high sympathetic nerve activity. In this age-group high resting heart rates and high plasma norepinephrine levels (independent of blood pressure) are linked to premature cardiovascular events and death. Thus, anti-hypertensive agents that increase sympathetic nerve activity ie diuretics, dihydropyridine calcium blockers, and ARBs, are inappropriate first-line choices in this younger age-group. Beta-blockers perform well vs randomised placebo and other antihypertensive agents regarding reduced risk of death/stroke/myocardial infarction in younger (<60 years) hypertensive subjects, and are a reasonable first-line choice of therapy (certainly in men). These facts should be reflected in the recommendations of guideline committees around the world.

Antihypertensive prescriptions over a 10-year period in a large Chinese population

BACKGROUND

International guidelines recommending antihypertensive prescriptions for the management of hypertension have been published in the past decade. Beta-blocker use was discouraged by a significant body of evidence and angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) were found more effective among younger patients. This study aims to evaluate the trends in prescription profiles in a large Chinese population because patterns of antihypertensive agent dispensation represent important information for physicians and policymakers.

METHODS

From clinical databases consisting of all patient records in the public health-care system of Hong Kong, we examined all antihypertensive prescriptions according to the drug classes (thiazide diuretics, alpha-blockers, beta-blockers, calcium channel blockers (CCBs), ACEIs, ARBs, fixed-dose combinations, and polytherapy (2, ≥3)) between 2001 and 2010. We retrieved >6.3 million prescription episodes for 223,287 patients.

RESULTS

The average age of the patients was 59.9 years (SD = 17.6), and 54.8% were women. According to prescription episodes, the most commonly prescribed medications were beta-blockers (31.7%) and CCBs (29.2%), followed by ACEIs (13.9%), thiazide diuretics (5.0%), and alpha-blockers (4.5%). Between 2001 and 2010, the prescription proportions of beta-blockers decreased from 41.5% to 21.5%, whereas that of ARBs increased from 0.5% to 1.0% (P < 0.001, χ(2) test for trend). It was found that the decline of beta-blockers (71.0% to 35.4%) and increase in ARB prescriptions (0.4% to 1.0%) were particularly marked among younger subjects aged <55 years.

CONCLUSIONS

These findings provided information on the prescription patterns of antihypertensive agents in a large Chinese population. It sets a future research direction to study the various reasons influencing these drug class-specific trends.

Treatment of hypertension in obese patients

Obesity is a global pandemic and with its rise, its associated co-morbidities are increasing in prevalence, particularly uncontrolled hypertension. Lifestyle changes should be an anchor for the management of obesity-related hypertension; however, they are difficult to sustain. Drug therapy is often necessary to achieve blood pressure control. Diuretics, inhibitors of the renin-angiotensin system, and dihydropyridine calcium channel blockers are often used as first trio, with subsequent additions of mineralocorticoid receptor antagonists and/or dual alpha/beta blocking agents. While a number of agents are currently available, 50 % of hypertensive patients remain uncontrolled. A number of novel drug and invasive therapies are in development and hold significant potential for the effective management of obesity-related hypertension.

Type 2 diabetes mellitus and obesity in sub-Saharan Africa

While communicable diseases such as human immunodeficiency virus/acquired immune deficiency syndrome, malaria, and tuberculosis have continued to pose greater threats to the public health system in sub-Saharan Africa (SSA), it is now apparent that non-communicable diseases such as diabetes mellitus are undoubtedly adding to the multiple burdens the peoples in this region suffer. Type 2 diabetes mellitus (T2DM) is the most common form of diabetes (90-95%), exhibiting an alarming prevalence among peoples of this region. Its main risk factors include obesity, rapid urbanization, physical inactivity, ageing, nutrition transitions, and socioeconomic changes. Patients in sub-Saharan Africa also show manifestations of beta-cell dysfunction and insulin resistance. However, because of strained economic resources and a poor health care system, most of the patients are diagnosed only after they have overt symptoms and complications. Microvascular complications are the most prevalent, but metabolic disorders and acute infections cause significant mortality. The high cost of treatment of T2DM and its comorbidities, the increasing prevalence of its risk factors, and the gaps in health care system necessitate that solutions be planned and implemented urgently. Aggressive actions and positive responses from well-informed governments appear to be needed for the conducive interplay of all forces required to curb the threat of T2DM in sub-Saharan Africa. Despite the varied ethnic and transitional factors and the limited population data on T2DM in sub-Saharan Africa, this review provides an extensive discussion of the literature on the epidemiology, risk factors, pathogenesis, complications, treatment, and care challenges of T2DM in this region.

Diabesity: therapeutic options

A pathogenic relationship exists between type 2 diabetes and obesity. Over the last decade, the escalation in diabetes cases has paralleled the rapid increase in obesity rates, constituting a global health crisis. Environmental risk factors attributed to the global increase in obesity include the consumption of high-calorie, high-fat foods and inadequate physical activity. Obese individuals may also have a genetic predisposition for obesity. Both diabetes and obesity confer an elevated risk of developing a range of complications and comorbidities, including cardiovascular disease, hypertension and stroke, which can complicate disease management. This review examines the aetiology of the linkages between diabetes and obesity and the range of available therapies. Recent clinical evidence substantiating the efficacy and safety of incretin-based antidiabetic therapies is analysed, in addition to data on antiobesity therapeutic strategies, such as antiobesity agents, behaviour modification and bariatric surgery. Glucose control is often accompanied by weight-neutral or modest weight reduction effects with DPP-4 inhibitor treatment (sitagliptin, vildagliptin, saxagliptin) and weight loss with GLP-1 receptor agonist therapy (exenatide, liraglutide). Studies of antiobesity agents including orlistat, sibutramine and rimonabant have shown attrition rates of 30-40%, and the long-term effects of these agents remain unknown. Bariatric surgical procedures commonly performed are laparoscopic adjustable banding of the stomach and the Roux-en-Y gastric bypass, and have produced type 2 diabetes remission rates of up to 73%. Therapeutic strategies that integrate glycaemic control and weight loss will assume greater importance as the prevalence of diabetes and obesity increase.

Type 2 diabetes: where we are today: an overview of disease burden, current treatments, and treatment strategies

OBJECTIVE

To provide an overview of the disease burden and current strategies in the treatment of patients with type 2 diabetes.

DATA SOURCES

Medline search of all relevant clinical and review articles.

STUDY SELECTION

By the author.

DATA EXTRACTION

By the author.

DATA SYNTHESIS

The prevalence of diabetes in the United States has reached epidemic proportions with the total diagnosed and undiagnosed cases among people aged 20 years or older estimated at 12.9%, and it continues to rise at an alarming rate. This upsurge has been paralleled by an increase in rates of obesity. Type 2 diabetes accounts for up to 95% of diabetes cases and is often comorbid with hypertension and dyslipidemia.

CONCLUSION

Tight glycemic control is necessary for the management of type 2 diabetes, but progressive deterioration of beta-cell function can lead to a loss of glycemic control. Oral antidiabetes drugs and insulin are effective but do not always correct the associated metabolic and glucoregulatory dysfunctions, and hypoglycemia and weight gain are common adverse effects of these agents. A clear need exists for aggressive therapeutic options-particularly incretin-based agents-that can be combined with existing agents to preserve beta-cell function and halt the progression of type 2 diabetes.

Behavioral Medicine Review: Weight Control in a Land of Milk and Honey

Obesity and its cardiometabolic comorbidities are on a skyrocketing trajectory with ominous public health implications. Focusing on primary care as a microcosm of the broader obesity crisis, this review discusses considerations for the prevention and management of obesity and its associated risks.